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Politicians are more than anxious over negative public opinion on the National Health Service, falling over backwards to say that the NHS is "safe in our hands." Meanwhile, the Church of England is concerned about losing "market-share," especially over conducting funerals. One way of linking these two extremely large British institutions is in terms of life-style choices.

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Doctors in the UK are striking for the first time in over 40 years. This comes after months of failed talks between the government and the British Medical Association (BMA) regarding the controversial new junior doctor contract. We do so with a heavy heart, as it goes against the very ethos of our vocation. Yet the fact that more than 98% of us voted to do so, speaks volumes about the current impasse.

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In the late 1960s, an ugly little rhyme circulated in Britain’s declining industrial towns. At the time, seemingly unstoppable mass migration from Britain’s former colonies had triggered a succession of new laws aimed at restricting entry to Britain, followed by a new political emphasis on ‘race relations’ intended to quell international dismay and reduce internal racial tensions.

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The research literature on health inequalities (health differences between different social groups) is growing almost every day. Within this burgeoning literature, it is generally agreed that the UK’s health inequalities (like those in many other advanced, capitalist economies) are substantial.

The post Health inequalities: what is to be done? appeared first on OUPblog.

The National Health Service (NHS) has never just been about the state’s provision of universal healthcare. Since 1948, it has been invested with a spectrum of ‘British values’, including decency, fairness, and respect. Featured in the Opening Ceremony of the London 2012 Olympic Games, and hailed in polls as the thing that makes people most proud of being British, the NHS enjoys widespread affection.

The post Does everyone love the National Health Service? Uncovering history’s critics appeared first on OUPblog.

By Simon Howell

Major trauma impacts on the lives of young and old alike. Most of us know or are aware of somebody who has suffered serious injury. In the United Kingdom over five-thousand people die from trauma each year. It is the most common cause of death in people under forty. Many of the fifteen-thousand people who survive major trauma suffer life-changing injuries and some will never fully recover and require life-long care. Globally it is estimated that injuries are responsible for sixteen-thousand deaths per day together with a large burden of people left with permanent disability. These sombre statistics are driving a revolution in trauma care.

A key aspect of the changes in trauma management in the United Kingdom and around the world is the organisation of networks to provide trauma care. People who have been seriously hurt, for example in a road traffic accident, may have suffered a head injury, injuries to the heart and lungs, abdominal trauma, broken limbs, and serious loss of skin and muscle. The care of these injuries may require specialist surgery including neurosurgery, cardiothoracic surgery, general (abdominal and pelvic) surgery, orthopaedic surgery, and plastic surgery. These must be supported by high quality anaesthetic, intensive care, radiological services and laboratory services. Few hospitals are able to provide all of the services in one location. It therefore makes sense for the most seriously injured patients to be transported not to the nearest hospital but to the hospital best equipped to provide the care that they need. Many trauma services around the world now operate on this principle and from 2010 these arrangements have been established in England. Hospitals are designated to one of three tiers: major trauma centres, trauma units, and local emergency hospitals. The most seriously injured patients are triaged to bypass trauma units and local emergency hospitals and are transported directly to major trauma centres. While this is a new system and some major trauma centres in England have only “gone live” in the past two years, it has already had an impact on trauma outcomes, with monitoring by the Trauma Audit and Research Network (TARN) indicating a 19% improvement in survival after major trauma in England.

Not only have there been advances in the organisation of trauma services, but there have also been advances in the immediate clinical management of trauma. In many cases it is appropriate to undertake “early definitive surgery/early total care” – that is, definitive repair of long bone fractures within twenty-four hours of injury. However, patients who have suffered major trauma often have severe physiological and biochemical derangements by the time they arrive at hospital. The concepts of damage control surgery and damage control resuscitation have emerged for the management of these patients. In this approach resuscitation and surgery are directed towards stopping haemorrhage, performing essential life-saving surgery, and stabilising and correcting the patient’s physiological state. This may require periods of surgery followed by intervals for the administration of blood and clotting factors and time for physiological recovery before further surgery is undertaken. The decision as to whether to undertake early definitive care or to institute a damage control strategy can be complex and is made by senior clinicians working together to formulate an overview of the state of the patient.

Modern radiology and clinical imaging has helped to revolutionise modern trauma management. There is increasing evidence to suggest that early CT scanning may improve outcome in the most unstable patients by identifying life-threatening injuries and directing treatment. When a source of bleeding is identified it may be treated surgically, but in many cases interventional radiology with the placement of glue or metal coils into blood vessels to stop the bleeding offers an alternative and less invasive solution.

The evolution of the trauma team is at the core of modern trauma management. Advances in resuscitation, surgery, and imaging have undoubtedly moved trauma care forward. However, the care of the unstable, seriously injured patient is a major challenge. Transporting someone who is suffering serious bleeding to and from the CT scanner requires excellent teamwork; parallel working so that several tasks are carried out at the same time requires coordination and leadership; making the decision between damage control and definitive surgery requires effective joint decision-making. The emergence of modern trauma care has been matched by the development of the modern trauma team and of specialists dedicated to the care of seriously injured patients. It is to this, above all, that the increasing numbers of survivors from serious trauma owe their lives.

Dr Simon Howell is on the Board of the British Journal of Anaesthesia (BJA) and is the Editor of this year’s Postgraduate Educational Issue: Advances in Trauma Care. This issue contains a series of reviews that give an overview of the revolution in trauma care. The reviews expand on a number of presentations that were given at a two-day meeting on trauma care organised by the Royal College of Anaesthetists in the Spring of 2014. They visit aspects of the trauma patient’s journey from the moment of injury to care in the field, on to triage, and arrival in a trauma centre finally to resuscitation and surgical care.

Founded in 1923, one year after the first anaesthetic journal was published by the International Anaesthesia Research Society, the British Journal of Anaesthesia remains the oldest and largest independent journal of anaesthesia. It became the Journal of The College of Anaesthetists in 1990. The College was granted a Royal Charter in 1992. Since April 2013, the BJA has also been the official Journal of the College of Anaesthetists of Ireland and members of both colleges now have online and print access. Although there are links between BJA and both colleges, the Journal retains editorial independence.

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By Paul Harriman

There is a truism in the world that quality costs, financially. There is a grain of truth in this statement especially if you think in a linear way. In healthcare this has become embedded thinking and any request for increasing quality is met with a counter-request for more money. In a cash-strapped system the lack of available money then results in behaviour that limits improvement. However, as an ex-colleague once said “we have plenty of money, we just choose to spend it in the wrong places”. This implies that if we were to un-spend it in the wrong place we would have plenty of spare cash.

The problem in healthcare, as in most service organisations, is that the system that delivers client value (in this case healthcare to patients) isn’t visible to those working in it. Indeed the only person that see’s the invisible system is the patient receiving that care. Our first task is to make the system visible and we can do this by producing a process map; a series of boxes describing the various activities all linked by one or more arrows. These maps can range from very high level to extremely detailed; the trick is to choose wisely and to look at the process from the patient’s perspective. Having produced your map the next step is to put some data onto it. Once you understand the process you can then start to hypothesise a different way of undertaking the work. Ask yourself;

• would pay your own money for a particular step; if not, then question why it exists
• are the steps in the right order?
• do they require roughly equal amounts of resource
• are there any bottlenecks?

Some four years ago, supported by a grant from the Health Foundation, we started to ask ourselves some of these questions in relation to the delivery of care to frail elderly patients. The answers were, in some cases, completely counter-intuitive. We found that some elderly patients stayed in hospital for many weeks after they could have left. There were many and varied reasons for this but none of them were related to acute hospital care. It was the wider disjointed system with its multiple hand-offs and traditional organisational rules that governed this. It was no-one’s fault, yet it was everyone’s problem.

So like eating the proverbial elephant we decided to start somewhere. It needed an individual clinician to put their hand up and take that first step. That first step was to try something different for one day; if it didn’t work then nothing was lost. The step was tried and the world didn’t end. Instead we found out that changing our normal system of “batching emergency admissions together so that they could all be seen the next day thus maximising consultant efficiency” to “let’s see them as they come in” meant that we reduced the time from arrival to senior specialty review by half. We also found opportunity to remove potential harm.

Having repeated this three times a few other consultants chose to take the trip with us and we repeated the same test over three days. That worked. So we tried for a full week. That also worked. By this time, and we were now almost six months into the journey, a range of staff including consultants, nurses, therapists, ambulance staff, managers and secretaries had all been involved in the tests and had all in their own way contributed to testing the new design and delivery.

The next steps were profound. A suggestion from the clinical director that all the consultants should change their job plans (on the same day) to deliver the new service was met with no dissent. A first in my experience. The physical manifestation of the change, the birth of the Frailty Unit then followed a few weeks later.

What was the cost of this? In terms of real life spend very little. The physical reconfiguration was largely cash neutral. Yes we spent some real money on service improvement support and staff invested their time; in the great scheme of things this was petty cash. But did it really change anything? Some hard metrics showed that we increased the number of patients who were discharged within 48 hrs from 18% to 24% and we reduced the number of total specialty beds by almost a quarter. We didn’t increase our readmissions and our biggest surprise was that we decreased our in-hospital mortality. In softer terms we now see many patients on the day that they arrive; we know how to potentially change our outpatient service and the staff on the Frailty Unit have become masters of caring for Frail Elderly patients.

Involving staff + Improvement science = Better outcomes + Lower Cost

Paul Harriman MBA, TDCR, FETC, HDCR, DCR(R).  Paul originally trained as a Diagnostic Radiographer at the Middlesex Hospital qualifying in 1977. He worked in a number of hospitals and obtained his HDCR and TDCR qualifications before coming to Sheffield in 1986. Whilst working as a Superintendent Radiographer at the Royal Hallamshire Hospital, he undertook an MBA and was also selected to join the General Management Scheme. He has since held a number of posts within the Trust working both within clinical directorates and corporate functions.

Paul has major interests in system thinking, improvement science, the use of data for decision making and has been working with Statistical Process Control charts for over 20 years. The main focus of his current work is supporting Geriatric and Stroke Medicine, to understand, analyse and challenge the current work processes.  He and Kate Silvester were part of the Flow, Cost, Quality programme sponsored by the Health foundation. He is a co-author of the paper ‘Timely care for frail older people referred to hospital improves efficiency and improves mortality without the need for extra resources‘ for the journal Age and Ageing.

Age and Ageing is an international journal publishing refereed original articles and commissioned reviews on geriatric medicine and gerontology. Its range includes research on ageing and clinical, epidemiological, and psychological aspects of later life.

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Image credit: Blue tone of beds and machines in hospital. By pxhidalgo, via iStockphoto.

The post You can save lives and money appeared first on OUPblog.

        

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By David Ellwood

“The Americanisation of British politics has been striking this conference season,” declared The Economist last autumn. “British politicians and civil servants love freebies to the US ‘to see how they do things,’” reported Simon Jenkins in The Guardian in November. Among the keenest such travellers is Michael Gove, the Education Secretary. Talking to the Daily Telegraph in February 2014, Gove spoke of the entrepreneurial spirit he found in California, and how his contacts with Microsoft and Google were helping him bring the skills of Silicon Valley to Britain. Perhaps Gove simply didn’t know how many UK governments of recent decades have journeyed along the same road, with the same aims. When Chancellor, Gordon Brown was tireless in his efforts to get British business “to rival America’s entrepreneurial dash,” as he told the same Daily Telegraph in December 2003, with speeches, conferences, educational programmes and other gestures, including visits from stars such as Bill Gates and Alan Greenspan.

One of the resources the British governing class most often turns to in its search for a successful, competitve identity for their country is ‘America’. Not American policy or money of course, not even that ‘Special Relationship’ which London clings on to so forlornly. Instead it’s an inspirational version of the United States: a source of models, examples, energies, ideas, standards; an invoked America whose soft power influence and prestige never fade. It is a form of virtual political capital which governments from Thatcher to Cameron feel they can draw on to compensate them for all their frustrations in Europe, their humiliations in the wider world and the intractability of their problems at home.

Overlooked by all the commentators without exception, there has long been an American question in Britain’s identity debate. It has not been put there by artists, experts, army officers, sports personalities or even Rupert Murdoch. It has been imported systematically and with great persistence by the governments of the last thirty years, and with it they have brought a series of possible answers. The underlying purpose has been to solve the identity crisis by way of ceaseless efforts to ‘modernise’ the nation, to renew its democracy but also to raise its ranking in those league tables of world competitiveness which the land of Darwin takes so seriously, and — of course — to distinguish it from everything supposedly going on in the European Union. Where better than America to find inspiration and encouragement for this permanent revolution of change the governing class repeatedly insists on?

A visionary image of the United States was central to Margaret Thatcher’s political revolution of the 1980s. As she told a Joint Session of Congress in 1985: “We are having to recover the spirit of enterprise which you never lost. Many of the policies you are following are the ones we are following.” Employment policy was one of the first examples, with reforms explicitly modelled on Reaganite ideology and experience. Even the wording of legislation was directly copied. Under Thatcher, Blair and Brown, certain public sectors, in particular the school and university systems, were reformed again and again in the hope of hooking them up to the motor of economic growth in the way their equivalents were thought to function in the United States. Since the 1980s, the Home Office has been the most zealous of departments in importing American methods and innovations. Simon Jenkins says: “An American friend of mine spent much of his time showing British officials around New York’s police department after its recent success in cutting crime.” Labour’s recent prime ministers were both enthralled by America’s examples. Gordon Brown proposed that school children should swear allegiance to the Union Jack, that there be a British Fourth of July, and a museum celebrating great documents of British democracy. Blair and Brown were the ones who started introducing American private health care firms into the running of the NHS.

David Cameron has followed the American path laid down by Thatcher, Blair, and Brown with zeal and ambition at least equal to theirs. The Tory foreign policy platform for the 2010 election was written by a Brit sitting in the Heritage Foundation in Washington. Just as the outgoing Labour administration created a British Supreme Court, the incoming coalition has set up a new National Security Council, with a National Security Adviser. In November 2012 the country was called upon to elect its first police commissioners, and there was talk of a single school commissioner. Now the Prime Minister talks of life sentences really meaning life in prison. All of this is based on American precedents. But Cameron’s affiliations in America seem to be deepest in parts of California where even Tony Blair did not reach, in particular the Google Corporation. A featured speaker at Google Zeitgeist conferences, Cameron is said to believe that the internet revolution as configured by Google, “meshes with the modern conservative mission – flattening hierarchies and empowering people…” Across Silicon Valley, Cameron and his strategists see a land where “a dynamic economy meets the family-friendly work-place…where hard-headed businessmen drink fruit smoothies and walk around in recycled trainers,” as an admiring journalist put it.

The evidence of the last 40-odd years suggests that in their failure to invent a generally agreed moral theme or narrative of change for their society, the British governing class clings to the America of their imaginations to fill the void. Not because the creed of Americanism as such, far less American politics as currently displayed, can provide the cohesiveness required but simply because US experience over time appears to show how a uniquely powerful machine of national pride and aspiration, embodied in institutions, rituals, stories, and proclaimed values, can keep a multicultural nation glued together and provide ever-lasting hope of renewal. With its exceptional levels of child poverty, social inequality and numbers of people in jail, the governments of the last 30 years may not have got the Americanised Britain they dreamed of. But this has not discouraged them. After all, Ministers know that their enthusiasms can always count on a far warmer reception across the Atlantic than anywhere else in the world, including in Britain itself.

David Ellwood is Senior Adjunct Professor of European Studies at Johns Hopkins University School of Advanced International Studies, Bologna Center. He is the author of The Shock of America: Europe and the Challenge of the Century. His first major book was Italy 1943-1945: The Politics of Liberation (1985) then came Rebuilding Europe: Western Europe, America and Postwar Reconstruction (1992). The fundamental theme of his research — the function of American power in contemporary European history — has shifted over the years to emphasize cultural power, particularly that of the American cinema industry. He was President of the International Association of Media and History 1999-2004 and a Fellow of the Rothermere America Institute, Oxford, in 2006. Read more from David Ellwood on OUPblog.

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Image credit: Supreme Court of the United States. By US Capitol. Public domain via Wikimedia Commons

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By Anayo Akunne

Delirium is a common but serious condition that affects many older people admitted to hospital. It is characterised by disturbed consciousness and changes in cognitive function or perception that develop over a short period of time. This condition is sometimes called “acute confusional state.”

It is associated with poor outcomes. People with delirium have higher chances of developing new dementia, new admission to institutions, extended stays in the hospital, as well as higher risk of death. Delirium also increases the chances of hospital-acquired complications such as falls and pressure ulcers. Poor outcomes resulting from delirium will reduce the patient’s health-related quality of life but also increase the cost of health care.

Delirium can be prevented if dealt with urgently. Enhanced care systems based on multi-component prevention interventions are associated with the potential to prevent new cases of delirium in hospitals. Prevention in a hospital or long-term care setting will lead to the avoidance of costs resulting from patients’ care. For example, the cost of caring for a patient with severe long-term cognitive impairment is high, and prevention of delirium could reduce the number of patients with such impairment. It will therefore reduce the cost of caring for such patients. Prevention could reduce lost life years and loss in health-related quality of life due to other adverse health outcomes associated with delirium.

The multi-component prevention interventions involve making an assessment of people at risk in order to identify and then modify risk factors associated with delirium. Delirium risk factors targeted in such interventions normally include cognitive impairment, sleep deprivation, immobility, visual and hearing impairments, and dehydration. The people at risk of delirium have their risk of delirium reduced through such interventions. The implementation of these interventions is usually done by a trained multi-disciplinary team of health-care staff. This means additional implementation cost. It would therefore be useful to know if this set of prevention interventions would be cost-effective. It was indeed found to be convincingly cost-effective by the UK National Institute for Health and Clinical Excellence (NICE) and was recommended for use in medically ill people admitted to hospital.

It is cost-effective to target multi-component prevention interventions at elderly people at both intermediate and high risk for delirium. It is an attractive intervention to health-care systems. In the United Kingdom the savings for the intervention would spread unevenly between the National Health Service (NHS) and social care providers. The savings to the NHS may be modest and largely accrue through lower costs resulting from reduced hospital stay, whereas the savings to social care are likely to be more considerable resulting from an enduring and diminished burden of dependency and dementia, particularly reduced need for expensive care in long-term care settings. The NHS acute providers may need to invest to implement the intervention and to accrue savings to the wider public sector. The current NHS hospital funding system does not incentivise this type of investment, and this could be a major structural barrier to a widespread uptake of delirium prevention systems of care in the UK.

In the work undertaken as part of the NICE guideline on delirium, the additional cost of implementing the intervention was based on the description of the intervention that required additional staff for delivery. It is possible that the guideline provides an important under-estimate of cost-effectiveness. This is because it might be possible to implement the intervention within existing resources. The intervention is designed to address risk factors for delirium by delivering the sort of person-centred routine c

As we peek into the future to see just what life will be like in the UK in 2020, a grim sight lies before us…

Power is now firmly in the hands on the heavily armed, tear-away children, nurtured by the recent Labour government, and statistics show over half the population is now Muslim. Christianity is an underground religion, practiced secretly, for fear of retribution, and the NHS has decided it will ONLY treat foreigners. Council houses are reserved exclusively for gypsies, asylum-seekers and paedophiles. And education (in the areas it’s still available face-to-face) is a guarded operation, with the teacher sitting behind bullet-proof glass and children wearing full body-armour (with an army of translators at the ready). Adults have resorted to leaving their boarded-up homes only in large gangs, or in tanks provided by the army. (The army is now boasting such fine military planners as the two prospective young terrorists recently found not guilty of planning toblow up their school, after hoping to kill hundreds of their innocent schoolmates.) 

Image via Wikipedia

The newly elected Lib-Dem goverrnment - voted inafter the late Conservative leader, David Cameron, was discovered to be nothing but a holographic image, projected by the President of America (as was Tony Blair), in order to control our country from afar – are using the military police to import illegal drugs, bought from the Afghan government, in order to keep the children on the streets as calm as possible. They still believe there’s some way out ofthis mess. 

Image via Wikipedia

Anyone who was able jumped ship years ago. Now only the poorest remain, along with the millions of half-blind elderly people who’ve been imprisoned for failing to pay the fines handed out for recycling offences (such as accidentally disposing of a potato peeling in the box designated for tin cans).

Image via Wikipedia

Aaah, but such is life!

As we peek into the future to see just what life will be like in the UK in 2020, a grim sight lies before us…

Power is now firmly in the hands on the heavily armed, tear-away children, nurtured by the recent Labour government, and statistics show over half the population is now Muslim. Christianity is an underground religion, practiced secretly, for fear of retribution, and the NHS has decided it will ONLY treat foreigners. Council houses are reserved exclusively for gypsies, asylum-seekers and paedophiles; inner-city areas resemble scenes from District 9.

Education (in the areas it’s still available face-to-face) is a guarded operation, with the teacher sitting behind bullet-proof glass and children wearing full body-armour (with an army of translators at the ready). Adults have resorted to leaving their boarded-up homes only in large gangs, or in tanks provided by the army. (The army is now boasting such fine military planners as the two prospective young terrorists recently found not guilty of planning to blow up their school, hoping to kill hundreds of innocent school friends and teachers.) 

Image via Wikipedia

The newly elected Lib-Dem government - voted in after the late Conservative leader, David Cameron, was discovered to be nothing but a holographic image, projected by the President of America (as was Tony Blair), in order to control our country from afar – are using the military police to import illegal drugs, bought from the Afghan government, in order to keep the children on the streets as calm as possible. They still believe there’s some way out of this mess…

Image via Wikipedia

Anyone who was able to jumped ship years ago. Now only the poorest remain, along with millions of half-blind elderly people who were imprisoned for failing to pay the fines handed out for their recycling offences (such as accidentally disposing of a potato peeling in the box designated for tin cans).

Image via Wikipedia

Suicide is now the only option.

In 1996, Alan Sokal, a Professor of Physics at New York University, wrote a paper for the cultural studies journal Social Text, entitled: Transgressing the Boundaries: Towards a transformative hermeneutics of quantum gravity. It was reviewed, accepted, and published. Sokal immediately admitted that the whole article was a hoax - a cunningly worded paper designed to expose and parody the style of extreme postmodernist criticism of science. The story became front-page news across the world. Sokal has now written a book for OUP called Beyond the Hoax: Science, Philosophy and Culture, which publishes in the UK this week. In the below post, Sokal writes about taking evidence seriously, and the implications it has for public policy.

This blog originally appeared on The Guardian’s Comment is Free site.

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